Accurate reporting depends on knowing the difference between what you observe and what the client tells you. This is a favourite exam topic.
Objective Information
What you can see, hear, feel, or measure — the facts. "Temperature 38.5°C," "ate half of lunch," "redness on left heel."
Subjective Information
What the client tells you — feelings and symptoms. "I feel dizzy," "my hip hurts." Record in the client's own words when you can.
Why It Matters
- The care team needs facts, not guesses.
- "Client seems sad" is opinion; "crying, says she misses home" is better.
- Quote the client for subjective reports.
- Never chart an assumption as a fact.
Putting It Together
Good notes often include both: what the client reported and what you observed — clear and separate.
🔑 Key Takeaways
- Objective = see, hear, feel, measure.
- Subjective = what the client tells you.
- Quote the client for subjective reports.
- Never chart an opinion as a fact.